Offer Of Alternative Employment
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1ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT
Division of Workers' Compensation, Reemployment Benefits Section
3301 Eagle Street, Suite 301, Anchorage, AK 99503-4149
OFFER OF ALTERNATIVE EMPLOYMENT
AWCB Case Number:
INSTRUCTIONS: This form must be used if the employer in #7 below wants to offer alternative employment to the employee under
AS 23.30.041(f)(1). It should accompany an Eligibility Evaluation Checklist and the evaluation report for reemployment benefits.
2. Date of Injury
1. Employee's Name (Last, First, Middle Initial)
3. Address
4. Social Security Number
City
State
Zip Code
5. Telephone
6. Date of Birth
7. Employer
8. Insurer/Adjusting Company
10. Address
9. Address
City
State
Zip Code
Telephone
City
State
Zip Code
Telephone
TO BE COMPLETED BY THE EMPLOYER:
11. Employer or a direct subsidiary offers alternative employment to Employee. The title of the offered job is
DOT No.
12. The job is scheduled to being on (date)
13. The gross hourly wage for the job is $
14. The job location is
15.
This offer of alternative employment is made in good faith because the job will prepare the employee to be employable in other jobs that
exist in the labor market at a comparable wage and physical demands.
16. Name of Employer/Subsidiary Representative
17. Representative's Title
18. Representative's Signature
19. Date Signed
TO BE COMPLETED BY THE REHABILITATION SPECIALIST:
20.
This job is within Employee's predicted permanent physical capacities based on a physician's approval of the attached job analysis
The employee's gross hourly wage at the time of the injury was
The wage in #13 above is equivalent to at least the state minimum wage under AS 23.10.065 or 75% of the employee's gross hourly
wages at the time of injury, whichever is greater.
This job prepares the Employee to be employable in other jobs that exist in the labor market as defined in AS 23.30.041(r)(3) at the
required wage and within the employee's physical capacities (Labor market documentation is attached)
Employee was informed of this job offer on
Employee
accept this offer
21. Name of Rehabilitation Specialist
22. Signature
23. Rehabilitation Specialist's Address and Phone Number
24. Date Mailed
Form 07-6151 (Rev 12/2012)
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